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Artificial nutrition
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=== '''Formulation''' === ** Macronutrients *** '''Carbohydrates''' - about 75% of calories supplied as glucose - aim about 2g/kg body weight/day **** The dextrose content is expressed as weight per volume: 5% dextrose means 5g dextrose per 100mL water *** '''Lipid''' emulsion is a soluble form of fat which allows it to be infused. Consists of an oil stabilised in an emulsion with egg yolk lecithin. No clinical benefit to giving fat in amounts greater than 30% of total energy. **** Rate of lipid clearance from blood does not reflect rate of oxidation - normal triglyceride levels doesn't guarantee the infusion rate is appropriate **** Lipid content usually expressed as a percentage of weight per volume, i.e. 10%, 20% or 30% are commonly used. *** '''Protein''' supplied as free amino acids - concentration expressed in terms of nitrogen content. Relatively low amounts of protein, about 1g/kg body weight/day. No evidence for using specific amino acids. ** Micronutrients *** Must be added separately, starting from the first day, since most patients getting TPN will also be deficient in micronutrients to start with *** Water-soluble vitamins **** B1 thiamine **** B2 riboflavin **** B3 niacin **** B5 pantothenic acid **** B6 pyridoxine **** B7 biotin **** B9 folic acid **** B12 cobalamin **** C ascorbic acid *** Fat-soluble vitamins **** A **** D **** E **** K *** Trace elements **** Chromium **** Copper **** Iodide **** Iron **** Manganese **** Molybdenum **** Selenium **** Zinc *** Electrolytes **** Sodium **** Magnesium **** Calcium **** Potassium **** Phosphorus ** '''Situations where formula is likely to need altering:''' *** Increased GIT losses - often needs more zinc, copper and selenium *** Biliary losses - need more copper and manganese *** Burns - more zinc, copper and selenium, as these are lost in burn exudate *** Pregnancy - no set recommendations *** Renal failure - caution - excretion of some trace elements is altered, so can overdose *** Liver disease - likely to be low in folate, vitamin C, thiamine, B group vitamins *** Refeeding syndrome - monitor for it
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